Monday, December 2, 2013

An Elderly Patient with a Fainting Spell

I was the primary care provider for an elderly 78 year old man who had been a patient in the clinic I worked in for several years.  Dan was very friendly and always appreciated my help.  He had made an urgent appointment to be seen that morning, so when I walked into see him early during my afternoon shift of patients, I knew something was up. 

“Sharon, I passed out yesterday morning at home.  I don’t remember what happened except I was feeling light-headed and then woke up on the floor of my bedroom.  Thankfully it’s carpeted, so I don’t have any nasty bruises anywhere.”

“Well, how long were you out and what did you do after you came to?”

“I don’t know how long I was out, probably for just a few seconds, I know it wasn’t longer than a minute.  I felt fine after I came to,  so I got up and finished getting ready for church.  My wife wasn’t happy with my not wanting to go to the emergency room, but I didn’t see any reason for it.  I finally told her I would come in here to be seen today, instead.”

“Okay.  Did anything else happen to you yesterday or this morning?”

“No, my wife and I went for our usual morning walk and then I’ve been home reading the newspaper and doing odds and ends.”

“Alright, well when people pass out like that it can mean they are having heart problems or problems with their thyroid for instance.  Is this the first time that you’ve passed out?”

“Yep.”

Risk factors for syncope (fainting)

Vasovagal reactions (a episode of simple fainting due to the patient smelling a strange odor for instance, or other similar episodes)
Changes in blood pressure (what is called orthostatic hypotension, there has to be a difference of >20 systolic/10 diastolic) when the patient has his blood pressure taken in the 3 different positions: laying, sitting and standing.
Diurectic medication which can deplete the blood pressure

“Okay, well then let me take a look at your labs for a minute and re-check the medications you’re on.  I seem to recall that you’re not on any water pills.”

“I’m not.  I’m just on my blood pressure meds and a medication for my cholesterol.  That’s it.”

I flipped through his paper chart (the clinic was getting ready to change over to an electronic health records, but we were still using paper charts at that time).  I quickly found the section with his lab results listed.  His thyroid had just been tested within the past six months and it was normal.  I flipped over to his medication list to make sure that he wasn’t on a diurectic which could deplete his blood volume too much and cause him to have a fainting episode.  Dan was right he wasn’t on any diurectics.  He was on a beta blocker and a calcium channel blocker for his blood pressure and cardiac angina.  He was also on a statin drug to keep his cholesterol levels in the normal range, as well as a daily aspirin.  I also knew from having taking care of Dan in the past that he was not one to drink any alcohol, nor smoke.

“Dan, when was the last time that you saw your cardiologist?” 

“I see him every six months for my angina.  I’m supposed to see him again I think in two weeks.  I haven’t had any problems with my angina since he started me on, hmm what’s it called, it starts with an n, umm Norvasc, that’s it.”

“Norvasc is your calcium channel blocker, it’s used for blood pressure and cardiac angina and it works very well for both.”

“Okay, so why did I pass out yesterday morning?”

“Well, I think you passed out because of your heart, I think you might have problems with what’s called atrial fibrillation, which is a common condition in elderly patients like you who have a history of high blood pressure and cardiac angina.  But I’m not sure as of yet.  So let me do a physical exam, then I’ll have the medical assistant come back in and take your vitals signs while you’re laying down, sitting and standing.  That will tell me whether you are having any orthostatic changes that could have caused your fainting spells.  I’ll also have her do a ECG on you to see whether there is any difference in your cardiac rhythm.  If that’s negative, then I’ll have you move your appointment up with your cardiologist and he’ll have to finish up the work-up.  Okay?”

“Whatever.  I just need to be able to tell my wife that I’m being taken care of.” 

Risk Factors for Atrial Fibrillation

Age
Hypertension
Cardiac surgery
Heart Failure
Hyperthyroidism (thyroid gland that is overactive)
Heart Attack
Myocarditis/Pericarditis (infection of the heart muscle or outer lining of the heart, the pericardium)
Acute lung disease
Cardiac arrhythmias (especially Wolff-Parkinson-White syndrome)
 
Symptoms of Atrial Fibrillation
 
Syncope (fainting)
Chest palpitations (feeling your heart beating)
Shortness of breath
Chest discomfort
Fatigue
Dizziness

So I proceeded to do his physical exam (which was negative and unchanged from prior visits) and then walked out of the exam room and asked the medical assistant to do his vitals in 3 positions (laying, sitting and standing).  After that I asked her to do a 12 lead electrocardiogram (ECG).  

After she had completed the ECG, she brought me his 3 sets of vitals signs (not enough of a change to classify him as having orthostatic hypotension).  His ECG showed the answer.  He had atrial fibrillation.  Prior to his QRS complex he didn’t have a clear P wave and had lots of waves before his ventricular contraction (QRS) would take place. 

I went in to talk with Dan and advise him that he needed to move up his appointment with his cardiologist. 

“Dan your ECG tells us what’s going on.  You have new onset atrial fibrillation.  As I handed him his ECG I pointed out the waves prior to the QRS complex.  Your cardiologist is going to have to do a 2 weeks study of your heart rhythms, where you will wear a constant monitor and then have you come back in to be seen by him.  From the 2 week study he’ll know how frequent your atrial fibrillation is and then he’ll decide on what to do about it.  He may also do another echocardiogram on you to assess any structural heart changes.  Something else he may also decide to do, is an acute cardioversion where he tries to shock your atrium out of it’s abnormal rhythm.  So with this in mind, I’m going to go call your cardiologist’s office and see whether we can get you into to be seen by him tomorrow.  I’ll be right back.”

I left his exam room to go out and call his cardiologist’s office.  I explained to the front desk person that I had a patient of Dr. Taylor in my office and that Dan needed to see him within the next 48 hours due to new onset atrial fibrillation.  As I expected she put me on hold to go talk to his nurse.  She came back and told me that he could see Dan on Wedsnesday morning at 8:30 am.  So I told her to go ahead and book the appointment and I went back into Dan to inform him of the appointment. 

“Dan, Dr. Taylor can see you on Wednesday morning at 8:30 am.  So make sure to keep this appointment.  Meanwhile I’ll fax over to his office the office note from today, your ECG and your thyroid results.  Any questions?”

“No, don’t think so.”

“Oh, and one more thing.  Seeing that you have an appointment so soon with Dr. Taylor I’m going to let him decide when to start you on Coumadin or Xarelto which will not allow the platelets to clump together.”

“Okay.”

“Alright, well I wish you well and I’ll find out what happened with Dr. Taylor when we receive the consultation note back.”

Treatment of Atrial Fibrillation

Beta-blocker medications which decreases the pulse rate
Calcium channel blockers which also decrease the pulse rate
Cardioversion or ablation or maze surgery (which would only be done at the time of open heart surgery)
Anti-coagulation (either Coumadin or Xarelto or a similar agent) – this prevents the platelets from sticking together, forming a clot due to the upper atriums of the heart not beating correctly.  Patients are anti-coagulated based on their CHADS score (CHADS score goes from 0-6, any score above a 2 requires that the patient be anti-coagulated).  Patients receive 1 point for each of the following: hypertension, age > 75, diabetes, heart failure.  Two are given for previous stroke or transient ischemic attacks.
If the patient has sick sinus syndrome (sinus tachycardia followed by sinus bradycardia, i.e. pulse above 100, then pulse below 40) then they can be treated with a pacemaker which paces the heart as well as addresses the atrial fibrillation. 

A few days later via fax, I received the consult note from Dr. Taylor.  He had seen Dan, ordered a follow-up echocardiogram on him and decided against trying to cardiovert him, per patient request.  So instead he had started him on Xarelto and discontinued his aspirin.  Dan was set up to have two weeks of his cardiac rhythms monitored.  He was to return to the clinic in two weeks which had been his originally scheduled appointment time. 

Two weeks later I received another follow-up note from Dr. Taylor.  Dan had completed his two weeks of monitoring, as well as his echocardiogram.  There wasn’t any change in his echocardiogram except the occassional atrial fibrillation.   His two weeks of monitoring showed that Dan was having episodes of atrial fibrillation that lasted for several minutes and then quit, only to re-start again. 

So Dr. Taylor decided to increase his beta blocker in an effort to acquire heart rate control.  Dan was scheduled to return to see him in follow-up in another two weeks.  Eventually, Dan’s atrial fibrillation was controlled with the increase in his beta blocker and he was symptom free.   

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